Design and Validation of the Marmara Post-prostatectomy
Incontinence Symptom Score
Marmara Post-prostatektomi İdrar Kaçırma Semptom Skoru Oluşturulması ve Validasyonu
Doi: 10.4274/jus.1097
Journal of Urological Surgery, 2017;4:1-7
Murat Akgül1, Muhammed Sulukaya2, Ahmet Şahan3, Nural Bekiroğlu4, İlker Tinay2, Levent Türkeri2, Tufan Tarcan2
1Tuzla State Hospital, Clinic of Urology, İstanbul, Turkiye
2Marmara University Faculty of Medicine, Department of Urology, İstanbul, Turkiye
3Ümraniye Training and Research Hospital, Clinic of Urology, İstanbul, Turkiye
4Marmara University Faculty of Medicine, Department of Biostatistics, İstanbul, Turkiye
Abstract
What’s known on the subject? and What does the study add?
Incontinence developing after post-prostatectomy is a very disturbing problem. There are many questionnaires for evaluating incontinence
in the field of urology. There is however no dedicated form which evaluates incontinence that develops particularly after prostatectomy. The
present study explores a valid and reliable questionnaire in analysis of post-prostatectomy incontinence.
Objective: This study aims to validate the “Marmara post-prostatectomy incontinence symptom score (M-PPISS)” designed for the assessment of
post-prostatectomy incontinence (PPI).
Materials and Methods: The questionnaire consists of 3 sections including 8 questions (4 questions examining the type and degree of PPI, 3
questions examining the effect of PPI on quality of life (QoL) and 1 question examining bladder emptying) and an analogue scale to assess the
impact of PPI on the QoL. The questionnaire was completed by 106 patients, who underwent radical prostatectomy (RP) in our clinic between 2007
and 2015, at the end of the first week, first month and at 3-month intervals up to one year after RP.
Results: The mean score of 106 patients at the end of the first week after the operation was 6.57 (minimum: 0, maximum: 24). The internal
consistency coefficient measured for our questionnaire was found to be higher (Cronbach’s alpha: 0.887). When an item was deleted, Cronbach’s
alpha was not lower than 0.85 for any value. According to the 27% rule, p value was calculated as 0.0001. In the numerical evaluation of total score
and the analogue scale considering QoL (satisfaction and dissatisfaction); patients with a total score of 0-4 were accepted as “satisfied with QoL”,
while patients with a total score of ≥5 were included in the dissatisfied group (cut-off value: 5).
Conclusion: The M-PPISS was found to be a reliable and valid instrument in the evaluation of urinary incontinence after RP.
Keywords: Prostatectomy, incontinence, questionnaire, validation
Amaç: Çalışmamızda prostatektomi sonrası idrar kaçırma (PSİK) değerlendirilmesi için oluşturduğumuz “Marmara post-prostatektomi idrar kaçırma
semptom skoru (M-PPİKSS)” validasyonu amaçlandı.
Gereç ve Yöntem: Sorgulama formu 3 bölümden oluşmakta ve idrar kaçırma şeklini ve miktarını sorgulayan 4 soru, idrar kaçırmanın yaşam kalitesi
üzerine olan etkilerini sorgulayan 3 soru ve mesane boşaltımını sorgulayan 1 soru olmak üzere toplam 8 soru bulunmaktadır. Bu sorgulama formu
kliniğimizde 2007-2015 yılları arasında radikal prostatektomi (RP) operasyonu uygulanan hastalardan 106 tanesine operasyon sonrası 1. hafta, 1. ay
ve 3 aylık kontrolleri sırasında dolduruldu ve sonuçları sorgulama formunun validasyonu açısından değerlendirildi.
Bulgular: Ameliyat sonrası 1. haftada toplam 106 hastanın ortalama skorları 6,57 (minimum: 0, maksimum: 24) olarak bulundu. Sorgulama formu
için hesaplanan iç tutarlılık katsayısı yüksek tespit edildi (Cronbach’s alfa: 0,887). Öğe silindiğinde Cronbach’s alfanın hiçbir değer için 0,85’in
altına düşmediği izlendi. %27 kuralına göre ise p değeri 0,0001 olarak hesaplandı. Toplam skor ile analog skala arasında yaşam kalitesi düşünülerek
Introduction
Incontinence, which develops after surgical interventions for
prostatic diseases such as prostate cancer (PC) and benign
prostatic hyperplasia, is a disturbing problem and affects a
significant group of patients with varying intensity (1). Radical
prostatectomy (RP) remains the most common treatment
option for the treatment of localized PC (2). However, in spite
of the advances in the techniques and technology, post-RP
incontinence affects 4 to 50% of patients mildly and 0 to 15.4%
of patients severely (3,4,5).
Besides routine urological evaluation for post-RP incontinence,
using a questionnaire can be helpful for the assessment of the
nature and quantity of the incontinence and its effect on the
quality of life (QoL). There are a number of questionnaires for
evaluating incontinence in the field of urology. Those forms
are important for the purpose of standardizing the information
received from the patients and eliminating subjectivity and,
such questionnaires are recommended to be used in daily
practice (6). There are 4 questionnaires, which are validated,
investigating incontinence and impotence after RP (7,8,9,10).
However, the need for a brief and dedicated questionnaire
still exists for the evaluation of incontinence developing
particularly after RP.
In this study, we aimed to introduce and validate the “Marmara
post-prostatectomy incontinence symptom score (M-PPISS)”
form for the evaluation of post-prostatectomy incontinence.
Materials and Methods
The M-PPISS questionnaire consists of 3 sections with a total of
8 questions (Annex 1). In the first section, there are 4 questions
regarding the type and severity of incontinence where five
different answers can be given from (0) never to permanently/
frequently (4). In the second section, there are 3 questions,
questioning the effects of incontinence on the QoL, where four
different answers can be given from (0) never to very much (3).
And in the last section, there is 1 question questioning bladder
emptying, where four different answers can be given from (0) (I
urinate comfortably) to 3 (I cannot urinate at all).
Total scores vary between 0 and 28. Furthermore, there is an
analog scale which helps to evaluate the overall QoL related to
micturition status at the end of the questionnaire. Such analog
scale is in the range I am happy (0) - I feel miserable (6).
For the validation of the questionnaire, a total of 106 patients,
who underwent RP operation in our clinic between 2007 and
2015, completed the M-PPISS at the 1st week, 1st month and 3
months controls after the RP.
Statistical Analysis
Validity and reliability analyses were performed using SPSS 17.0
software. A p value of less than 0.05 was considered statistically
significant.
Results
The average age of the 106 patients, who completed the M-PPISS
questionnaire, was 63.9±6.4 years. The average M-PPISS scores
of the patients are presented in Table 1, where continuous
decreases were observed with longer follow-up periods (Table 1).
After test-retest analysis carried out by means of comparing
1st week, 1st month and 3 monthly M-PPISS during follow-up,
where significant differences were observed in the answers
given by the patients to each question, in total score and in
averages (p<0.05).
The internal consistency coefficient calculated for the
questionnaire was high (Cronbach’s alpha: 0.887) and when
an element was deleted for each question within the M-PPISS
questionnaire, Cronbach’s alpha value did not drop below 0.85
for any value (Table 2).
The correlation analysis of the M-PPISS total score and analog
scale is given in Table 3, where the “27% rule” applied for the
M-PPISS questionnaire form has been found to be significant at
an advanced level (p=0.0001).
A total score between 0 and 4 was considered satisfactory with
regard to QoL, while a total score of ≥5 was interpreted as
unsatisfied (threshold: 5) (Figure 1). Numerical evaluation was
performed between total score and analog scale (satisfaction
and dissatisfaction) and the sensitivity was calculated as 91.1
and specificity as 85.2.
Discussion
Although the international literature describes questionnaires
and specific scales for incontinent patients, instruments
specific for post-RP incontinence are scarce. The M-PPISS
shows excellent internal consistency and reliability.
Furthermore, the test-retest correlation, which is another
measurement of reliability, has also been found to be high.
The threshold value we offer for the total score is 5 and as
evident in the receiver operating characteristic curve, beyond
such threshold is the value with highest sensitivity (91%) and
specificity (85%).
Incontinence is a significant QoL issue after RP and post-
prostatectomy incontinence has been reported at various levels
and rates (3,4,5). With the advancing techniques for preservation
of the neurovascular bundle, provision the length of the
remaining urethra at a maximum level and creation of vesico-
uretral anastomoses, post-RP urine control rates are maintained
at a higher level (11). The first detailed study on the influence
of post-RP problems was carried out by Fowler et al. (12) in
1995 using “Medicare database” and 89% of the patients stated
that they would prefer surgery to other treatment options as it
provided better cancer control in spite of post-RP incontinence
and impotence complaints. Fortunately, the urinary control
increases as the time advances after the operation. In a study
carried out by Lepor and Kaci (13), in a two-year post-RP
follow-up, 71%, 87%, 92% and 98.5% of patients achieved
continence, which was defined as the use of no pad or a single
protective pad in a 24-hour period, in 3rd, 6th, 12th and 24th
months, respectively.
Post-RP incontinence is known to affect the QoL significantly
(14). There are questionnaires assessing the complaints of
incontinence and analyzing the effect of incontinence on
the QoL. The subjective data received from the patient will be
standardized from clinical and practical points of view using
these questionnaires (6). For this purpose, The International
Continence Society (ICS) recommends many questionnaires
aimed at assessing male incontinence. The most important one
among those is the ICSmaleSF questionnaire, which questions
urinary symptoms and their influence on QoL in benign
prostate hyperplasia (15). However, that form has been used in
patients suffering from incontinence due to benign lesions of
the prostate, and does not cover incontinence in patients who
underwent RP for PC.
The validated forms, which have been used frequently for the
assessment of post-RP incontinence, are summarized in Table 4
(16). The University of California-Los Angeles Prostate Cancer
Index (UCLA-PCI) contains 20 questions related to post-RP
incontinence, impotence and intestinal problems of patients
(7). The Expanded Prostate Index Composite (EPIC) is a long
and comprehensive questionnaire consisting of 50 questions
Figure 1. The receiver operating characteristic analysis formed between total
score and analog scale, considering the quality of life
Table 1. Average scores of the patients in Marmara post-
prostatectomy incontinence symptom score
n Average Standard error
1st week 106 6.57 0.60
1st month 106 5.44 0.63
3rd month 104 4.12 0.56
6th month 103 3.75 0.53
9th month 97 3.38 0.54
12th month 91 2.89 0.54
Table 2. Cronbach’s alpha value when an element was deleted
for each question within the Marmara post-prostatectomy
incontinence symptom score questionnaire (n=106)
Question number Cronbach’s alpha value when an element
was deleted
1 0.875
2 0.874
3 0.857
4 0.873
5 0.861
6 0.862
7 0.877
8 0.894
Table 3. The Marmara post-prostatectomy incontinence
symptom score total score and correlation of the analog scale
Correlation coefficient r p
1st week 0.72 p=0.0001
1st month 0.82 p=0.0001
3rd month 0.70 p=0.0001
6th month 0.87 p=0.0001
9th month 0.79 p=0.0001
12th month 0.78 p=0.0001
asking incontinence, impotence and intestinal problems in
patients who underwent RP, radiotherapy or brachytherapy
for PC (8). This form was shortened as EPIC 26 and EPIC-CP
and, re-validations were performed (17,18). UCLA-PCI and
EPIC have been shown to be valuable and correlated with
each other with regard to their questioning of incontinence
and impotence as for QoL (19). The European Organization
for Research and Treatment of Cancer Core Quality of Life
Questionnaire with its PC-specific module (EORTC QLQ-C30-
PR25) has 25 additional prostate-specific questions related
to incontinence, sexual life and intestinal functioning,
questioning cancer treatment-related QoL (9). And the
Functional Assessment of Cancer Therapy-Prostate (FACT-P)
consists of 38 questions particularly aimed at assessing QoL
of males with metastatic disorder, of which 26 are general,
12 are specific to the disease (10). These questionnaires do
not specifically question incontinence, but assess negative
post-prostatectomy effects in general while the M-PPISS
questionnaire specifically questions incontinence and
analyses its effect on the QoL of the patient. The M-PPISS
is a short and dedicated questionnaire for the evaluation
of incontinence after RP with an internal consistency and
reliability.
Study Limitations
In the study design, test-retest validity and reliability assessed
by 1st week, 1st month and every 3 months forms. However,
the patient’s symptoms might relieve after RP and the patient’s
score may change according to convalescence. Performing test-
retest reliability in a stable health condition rather than the
patient population is lacking.
Conclusion
The M-PPISS was found to be a reliable and valid instrument in
the evaluation of urinary incontinence after RP. The M-PPISS is
specifically questioning incontinence and its effect on the QoL
and is a brief and easy-to-administer questionnaire for post-RP
incontinence.
Ethics
Ethics Committee Approval: Retrospective study, Informed
Consent: Retrospective study.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: Tufan Tarcan, Levent Türkeri, İlker Tinay, Murat Akgül,
Design: Tufan Tarcan, Levent Türkeri, İlker Tinay, Murat Akgül,
Data Collection or Processing: Murat Akgül, Muhammed
Sulukaya, Ahmet Şahan, Analysis or Interpretation: Nural
Bekiroğlu, Literature Search: Murat Akgül, Tufan Tarcan, İlker
Tinay, Writing: Murat Akgül, Muhammed Sulukaya.
Conflict of Interest: No conflict of interest was declared by the
authors.
Financial Disclosure: The authors declared that this study
received no financial support.
References
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Table 4. The most frequently employed post-radical
prostatectomy questionnaires
1. The UCLA Prostate Cancer Index (PCI):
The questionnaire consisting of 20 questions specific to prostate.
2. The Expanded Prostate Cancer Index-Composite:
Extended version of the UCLA PCI questionnaire including 30
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module:
25 additional questions specific to prostate regarding incontinence,
sexual life and intestinal functioning, questioning the cancer
treatment-related quality of life.
4. The Functional Assessment of Cancer Therapy-Prostate:
The questionnaire consisting of 38 questions particularly aimed at
assessing the quality of life of males with metastatic disorder, of
which 26 are general, 12 are specific to the disease.
UCLA: The University of California-Los Angeles
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Design and Validation of the M-PPISS
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Ek 1: M-PPİKSS sorgulama formu
1. Bir günde kaç ara bezi değiştiriyorsunuz?
Hiç (0) (1) (2) (3) 4 ve daha çok
2. Kullandığınız pet büyüklüğü nedir?
(0) Pet kullanmıyorum
(1) Küçük pet (Avuç içi büyüklüğünde)
(2) Çocuk bezi
(3) Büyük hasta bezi
(4) Prezervatif sonda kullanıyorum
3. Değiştirdiğiniz pet ne kadar ıslanıyor?
(0) Hiç ıslanmıyor
(1) Çok az ıslaklık oluyor
(2) Yarısından azı ıslanıyor
(3) Yarısından fazlası ıslanıyor
(4) Tümüyle sırılsıklam oluyor
4. Ne zaman idrar kaçırıyorsunuz?
(0) Hiçbir zaman
(1) Ayağa kalkarken, yürürken
(2) Gülmekle, ıkınmakla, öksürmekle
(3) En ufak bir hareketle
(4) Sürekli
5. İdrar kaçırmanız günlük işlerinizi ne derecede etkiliyor?
(0) Hiç etkilemiyor, günlük işlerimi yapabiliyorum
(1) Az miktarda etkiliyor, günlük işlerimi çoğunlukla yapabiliyorum
(2) Orta derecede etkiliyor, günlük işlerimin bazılarını yapabiliyorum
(3) Ciddi derecede etkiliyor, günlük işlerimin çoğunu yapamıyorum
6. İdrar kaçırmanız arkadaşlarınızla olan ilişkileriniz ne derecede etkiliyor?
(0) Hiç etkilemiyor, ilişkilerimde değişiklik yok
(1) Az miktarda etkiliyor
(2) Orta derecede etkiliyor
(3) Ciddi derecede etkiliyor
7
Akgül et al.
Design and Validation of the M-PPISS
Journal of Urological Surgery,
2017;4:1-7
7. İdrar kaçırmanız psikolojik durmunuzu etkiliyor mu?
(0) Hiç etkilemiyor
(1) Az miktarda etkiliyor, hafif derecede sinirli ve gergin olmaktayım
(2) Orta derecede etkiliyor ve gergin oluyorum
(3) Ciddi derecede sinirli ve gergin oluyorum
8. İdrarınızı nasıl yapıyorsunuz?
(0) Rahat idrar yapmaktayım
(1) İdrar yapmada biraz zorlanıyorum
(2) İdrar yaparken çok zorlanıyorum ve kesik kesik idrar yapıyorum
(3) Hiç idrar yapamıyorum
Toplam Skor : _____________________________________________________________________________________________
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